Healthcare Provider Details

I. General information

NPI: 1053782896
Provider Name (Legal Business Name): HEATH JACKSON MAJOR M.S., ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2015
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 CROUCH DR
PENDLETON SC
29670-1513
US

IV. Provider business mailing address

703 CROUCH DR
PENDLETON SC
29670-1513
US

V. Phone/Fax

Practice location:
  • Phone: 864-617-0324
  • Fax:
Mailing address:
  • Phone: 864-617-0324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1450
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: